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Background: Over the last two decades, significant research interest has led to the development of a wide variety of supraglottic airways (SGAs) for anaesthesia providers to choose from., Methods: In this network meta-analysis, we analysed 111 studies, enrolling 12 045 patients undergoing airway management with 29 SGAs. We targeted outcomes that contribute to clinicians' choice of one SGA over another. The primary outcome was the incidence of postoperative sore throat (POST). Secondary outcomes were first-attempt insertion success, bleeding complications, and oropharyngeal leak pressure (OLP). Based on credible intervals, we created a 'rank order' to guide decision-making for clinicians., Results: The highest-ranking devices based on credible intervals for POST, bleeding complications, first-attempt insertion success, and OLP were LMA Ambu, Jcerity Endoscoper, LMA Blockbuster, and LMA Baska Mask, respectively. Air-Q and i-gel ranked favourably across multiple outcomes, with i-gel being the only device to rank within the top six SGAs for POST, bleeding, and first-attempt success despite ranking poorly for OLP., Conclusions: Our data support the use of LMA-Ambu, Jcerity-Endoscoper, Air-Q, and i-gel when considering patient-centred outcomes. Clinician familiarity with these devices and their continued expansion into anaesthetic practice will have important implications on the perioperative patient experience., Systematic Review Protocol: PROSPERO (CRD42022383136)., (Copyright © 2024 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Competing Interests: There are no conflicts of interest.

Objectives: Both superficial and deep serratus anterior plane (SAP) blocks are effective for anterior chest wall surgeries, but there is little clarity on which is more effective. Hence, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the comparative efficacy of the 2 approaches for SAP block after anterior chest wall surgery., Materials and Methods: A systematic literature search was performed using PubMed, Embase, Scopus, and Cochrane Central Registers of Controlled Trials for eligible RCTs from inception until August 2023. The primary outcome was opioid consumption during the first 24 hours of the postoperative period. The secondary outcomes included pain scores at various intervals, intraoperative opioid consumption, time to first analgesic request, block-related complications, opioid-related side effects, and patient satisfaction scores. Statistical analysis of the pooled data was performed using Review Manager Version 5.3., Results: We identified 7 RCTs published between 2020 and 2022, enrolling 371 patients (186 in the superficial SAP block and 187 in the deep SAP block). Moderate certainty of evidence suggests that both the approaches (deep and superficial) of SAP block were comparable for 24-hour oral morphine equivalent consumption with a mean difference (MD) of 3.78 mg (95% CI: -1.70 to 9.29; P = 0.18; I2 = 87%). The results of other secondary outcomes were comparable, including resting pain scores with an MD of 0.08 (95% CI: -0.27 to 0.43; P = 0.67; I2 = 87%) for early pain and MD of 0.63 (95% CI: -1.28 to 0.01; P = 0.05; I2 = 95%) for late pain scores, time to first analgesic request with MD of -0.41 hour (95% CI: -1.40 to 0.59; P = 0.42; I2 = 90%), and incidence of postoperative nausea and vomiting (odds ratio: 1.45 (95% CI: 0.72 to 2.90; P = 0.30; I2 = 0%)., Conclusion: Current evidence does not support the preference for one approach of SAP block over the other for postoperative pain. Based on the available data, we recommend further future trials to determine any differences between these interventions., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Aims: Postoperative neurocognitive dysfunction (PNCD) commonly occurs after surgery and prolongs hospital stays. Both direct noxious stimuli to the central nervous system and systemic inflammation have been implicated. Due to their potent anti-inflammatory effects, corticosteroids have been utilised to attenuate the incidence and severity of PNCD. This systematic review and meta-analysis strived to evaluate the prophylactic role of perioperative corticosteroids for PNCD., Methods: A search was run in pre-defined databases for randomised controlled trials (RCTs) assessing the role of corticosteroids in preventing PNCD. The incidence of PNCD within 1 month was the primary outcome. Secondary outcomes included the use of antipsychotic medications for the treatment, postoperative infection, and hospital length of stay. The results are exhibited as odds ratio (OR) and the mean difference (MD) with 95% confidence interval (CI)., Results: Fifteen RCTs comprising 15,398 patients were included. The incidence of PNCD was significantly lower in the corticosteroid group than in the control group, with a pooled OR of 0.75 (95% CI 0.58, 0.96; P = 0.02; I 2 = 66%). Trial sequential analysis showed the clinical benefit of corticosteroids in preventing PNCD; however, the requisite information size is still inadequate. The sub-group analysis supported the prophylactic effect of corticosteroids on delirium prevention but not on delayed neurocognitive recovery., Conclusions: Our meta-analysis revealed statistically significant protective effects of corticosteroids on the incidence of PNCD. However, further studies are still needed to confirm the protective role of this commonly used and relatively safe strategy for preventing PNCD., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Indian Journal of Anaesthesia.)

Background: Fasting before elective anesthesia care is a standardized practice worldwide. The aim is to decrease the risk of aspiration leading to pulmonary complications such as aspiration pneumonitis during anesthesia care. There are different guidelines for elective preoperative fasting in children. However, there is insufficient literature measuring gastric emptying time after breast milk or formula milk feeding in infants., Objective: This study used gastric ultrasound to determine the gastric emptying time for breast milk and formula milk in children below 6 months of age. We also compared the calculated gastric volumes among breast-fed and formula milk-fed based on Schmitz's and Spencer's formula., Materials and Methods: This prospective observational study was conducted at a tertiary care center in India between November (2017-2019). A total of 52 infants less than 6 months of age were recruited. The study population was divided into two groups (breast-fed and formula milk-fed) of 26 patients each. Ultrasound was used to measure the antral cross-sectional area of the stomach and to calculate the gastric volume using the two classical formulas (Schmitz and Spencer's). Gastric emptying was reported when the bull's eye appearance of the gastric antrum was seen or when the antral cross-sectional area was less than 3.07 cm 2 ., Results: The number of breast-fed children whose antral cross-sectional was greater than 3.07 cm 2 (cut-off value for aspiration risk) beyond 1 h was 14/26 (53.84%) while none (0) children went beyond 3 h. The number of formula-fed children whose antral cross-sectional was greater than 3.07 cm 2 beyond 1 h was 17/26 (65.38%) while one child (3.84%) went beyond 3 h. Using Schmitz's formula, mean (SD) gastric emptying times were 0.35 ± 0.68 h (95% CI 0.35 ± 0.185, range 0.165-0.535) for breast-fed patients and 0.35 ± 0.69 h (95% CI 0.35 ± 0.188, range 0.162-0.538) for formula-fed patients, and were thus neither clinically nor statistically different (p = .73) Using Spencer's formula, the mean gastric emptying times were 0.12 ± 0.33 h (95% CI 0.12 ± 0.09, range 0.03-0.21) for breast-fed patients and 0.04 ± 0.20 h (95% CI 0.04 ± 0.05, range -0.01 to 0.09) for formula-fed patients, and were also neither clinically nor statistically different p = .13., Conclusion: In our series, the gastric emptying times in breast-fed and formula-fed infants less than 6 months old were similar. Our results support the fasting guidelines of the European Society of Anaesthesiology and Intensive Care 2022, that is, 3 h for breastfeeding and 4 h for formula milk feeding. In addition, this shows that the Schmitz's and Spencer's formulae used to calculate the gastric volume based on ultrasound measurement of the antral cross-sectional area are not comparable in infants less than 6 months., (© 2024 John Wiley & Sons Ltd.)

Background: Rebound pain occurs after the resolution of peripheral nerve block and hampers patient recovery in the postoperative period. We sought to synthesise available data from randomised controlled trials (RCTs) evaluating the efficacy of prophylactic dexamethasone for rebound pain in adult patients undergoing surgery with a peripheral nerve block., Methods: In this systematic review and meta-analysis, RCTs reporting rebound pain and use of dexamethasone in the context of a peripheral nerve block were searched in various databases and updated in May 2023. The primary outcome was the incidence of rebound pain; secondary outcomes included the severity and time to onset of rebound pain, patient satisfaction with pain control, sleep disturbance because of pain, and adverse effects of dexamethasone. Subgroup analysis was conducted based on the effect of route of administration (intravenous or perineural) on the incidence of rebound pain. Trial sequential analysis was performed to rule out the possibility of a false positive result., Results: Seven RCTs comprising 574 patients were included in this review. The dexamethasone group was associated with a reduction in the incidence of rebound pain with an odds ratio of 0.16 (95% confidence interval 0.10-0.27, P=0.00, I 2 =0%) compared with the control group. Trial sequential analysis confirmed the adequate information size for the beneficial effect of dexamethasone. Subgroup analysis showed that both intravenous and perineural administration were associated with a significant reduction in the incidence of rebound pain., Conclusions: Current evidence suggests that both intravenous and perineural dexamethasone reduce the incidence of rebound pain after a peripheral nerve block provided for postoperative analgesia., Systematic Review Protocol: PROSPERO CRD42023424031., (Copyright © 2023 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Antler removal in deer is a common practice for various purposes, including meat production and traditional medicine. However, the current industry practice using lidocaine as a local anesthetic has limitations, such as short duration of action and the potential for postoperative infections. In this study, we investigated the performance of a ZnO collagen nanocomposites loaded with local anesthetics to improve wound management and alleviate pain associated with antler removal in red deer. The research involved the preparation of collagen nanocomposites with local anesthetics and testing the drug release rates using in vitro drug release tests. Pharmacokinetic analysis was performed to evaluate the total drug release from the collagen matrix in red deer after velvet removal. Additionally, the analgesic efficacy of these collagen nanocomposite dressings was assessed after antler removal in red deer. Functionalized ZnO nanoparticles were incorporated into collagen fibers to enhance their mechanical stability and prolong drug release. The developed collagen nanocomposites aimed to slowly release local anesthetics and promote wound healing. The findings of this research could have significant implications for improving the pain management and wound healing associated with antler removal in deer. The results obtained from the in vitro drug release tests, pharmacokinetic analysis, and analgesic efficacy evaluations provide valuable insights into the understanding and development of novel approaches for antler removal procedures in red deer. The findings contribute to the advancement of knowledge in this field and lay the foundation for future implementation of improved techniques and protocols for antler removal., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Recent literature indicates that post-COVID-19 patients suffer from a plethora of complications, including chemosensory dysfunction. However, little attention has been given to understand the interactions between chemosensory, trigeminal, and salivary dysfunctions in these patients. The aims of this study were (1) to investigate the prevalence and combinations of chemosensory, trigeminal, and salivary dysfunctions, (2) to identify the odorants/tastants that are compromised, and (3) to explore possible associations between the four dysfunctions in post-COVID-19 patients. One hundred post-COVID-19 patients and 76 healthy controls (pre-COVID-19) were included in this cross-sectional, case-controlled study. Participants' smell, taste, trigeminal, and salivary functions were assessed. The patients had a significantly higher prevalence of parosmia (80.0%), hyposmia (42.0%), anosmia (53.0%), dysgeusia (34.0%), complete ageusia (3.0%), specific ageusia (27.0%), dysesthesia (11.0%) and dry mouth (18.0%) compared to controls (0.0% for all parameters, except 27.6% for hyposmia). Complete loss of bitter taste was the most prevalent specific ageusia (66.7%) and coffee was the most common distorted smell (56.4%). Seven different combinations of dysfunction were observed in the patients, the most common being a combination of olfactory and gustatory dysfunction (48.0%). These findings indicate that post-COVID-19 patients experience a range of chemosensory, trigeminal, and salivary disturbances, occurring in various combinations., (© 2024. The Author(s).)

Pain mitigation strategies for disbudding in goat kids have gained significant attention in recent years because of growing concerns for animal welfare. Disbudding, the removal of horn buds in young goats, is a common practice to enhance safety and manage herd dynamics. However, the procedure will cause pain and distress if not managed effectively. This review covers the array of pain mitigation techniques currently available for disbudding, including the efficacy of these strategies in reducing pain and stress during the disbudding process, with specific attention to the potential toxicity associated with local anesthetics. The current best practice for disbudding on the farm suggests sedation/analgesia with an alpha-2 agonist, the placement of a two-point cornual nerve block, and then an NSAID for postoperative pain. In conclusion, this review offers recommendations for future research directions aimed at enhancing the welfare of young goats subjected to the disbudding procedure. These suggestions hold the promise of fostering significant improvements in the overall well-being of these animals.

Background/importance: Postoperative neurocognitive dysfunction (PNCD) is a frequent and preventable complication after surgery. The large high-quality evidence for the efficacy of supplemental regional analgesia blocks (RAB) for preventing PNCD is still elusive., Objective: The objective of this meta-analysis was to evaluate the effect of RAB versus standard anesthesia care on the incidence of PNCD in adult patients undergoing major non-cardiac surgery., Evidence Review: PubMed, EMBASE, Scopus, and the Cochrane Central Registers of Controlled Trials (CENTRAL) were searched for randomized controlled trials (RCTs) from 2017 until June 2022. The primary outcome was the incidence of PNCD within 1 month of surgery. A random-effects model with an inverse variance method was used to pool results, and OR and mean differences were calculated for dichotomous and continuous outcomes. Various exploratory subgroup analyses were performed to explore the possibility of the association between the various patient, technique, and surgery-related factors. Grading of Recommendation, Assessment, Development, and Evaluation guidelines were used to determine the certainty of evidence., Findings: Twenty-six RCTs comprizing 4414 patients were included. The RAB group was associated with a significant reduction in the incidence of PNCD with an OR of 0.46 (95% CI 0.35 to 0.59; p<0.00001; I 2 =28%) compared with the control group (moderate certainty). Subgroup analysis exhibited that the prophylactic efficacy of RAB persisted for both delirium and delayed neurocognitive recovery., Conclusions: Current evidence suggests that supplemental RAB are beneficial in preventing PNCD in patients after major non-cardiac surgery., Prospero Registration Number: CRD42022338820., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: In this study, we aimed to prepare enteric encapsulated spheroids containing inclusion complex using quality by design approach. Methods: A Box-Behnken design was employed to determine effects of variables on selected responses. Risk assessment was conducted using Ishikawa fishbone diagram. A model with a p -value was less than 0.5 for being a significant error of model was determined based on significance 'lack of fit' value. Spheroids were formulated using the extrusion spheronization technique and were characterized using analytical techniques. Results: In vitro release was performed in both acidic (pH 1.2) and simulated intestinal (pH 6.8) conditions. Permeability studies demonstrated tenfold enhancement compared with arteether. In vivo studies further validated increase of 51.8% oral bioavailability. Ex vivo studies revealed 3.4-fold enhancement in antimalarial activity compared with arteether. Conclusion: These findings highlight effectiveness of inclusion complexation technique as a viable approach to enhance solubility and bioavailability for drugs with low aqueous solubility.

In recent years, the growing demand for herbal-based formulations, including functional foods, has acquired significant attention. This study highlights historical, botanical, ecological, and phytochemical descriptions and different extraction mechanisms of Ocimum sanctum utilized in its processing. Besides this, it explores the utilization of Ocimum sanctum as a functional food ingredient in various food products such as bakery products (biscuits, bread), dairy products (herbal milk, cheese), and beverages (tea, juice, wine) while focusing on their evaluation parameters, preparation techniques, and pharmacological activities. In terms of other pharmacological properties, Ocimum sanctum -infused functional foods exhibited cognitiveenhancing properties, adaptogenic qualities, anti-obesity effects, gastroprotective, antiinflammatory, hypoglycemic, and immuno-modulatory effects. Thus, the diverse properties of Ocimum sanctum offer exciting opportunities for the development of functional foods that can promote specific health issues, so future research should focus on developing and analyzing novel Ocimum sanctum -based functional foods to meet the growing demand of the functional food industry., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background: The use of herbal medicines is on the rise throughout the world due to their perceived safety profile. However, incidences of herb-drug, herb-herb and herb-food interactions considering safety aspects have opened new arenas for discussion., Objective: The current study aims to provide comprehensive insights into the various types of herb interactions, the mechanisms involved, their assessment, and historical developments, keeping herbal safety at the central point of discussion., Methods: The authors undertook a focused/targeted literature review and collected data from various databases, including Science Direct, Wiley Online Library, Springer, PubMed, and Google Scholar. Conventional literature on herbal remedies, such as those by the WHO and other international or national organizations., Results: The article considered reviewing the regulations, interaction mechanisms, and detection of herb-herb, herb-drug and herb-food interactions in commonly used yet vital plants, including Glycyrrhiza glabra, Mentha piperita, Aloe barbadensis, Zingiber officinale, Gingko biloba, Withania somnifera, etc . The study found that healthcare professionals worry about patients not informing them about their herbal prescriptions (primarily used with conventional treatment), which can cause herb-drug/herb-food/herb-herb interactions. These interactions were caused by altered pharmacodynamic and pharmacokinetic processes, which might be explained using in-vivo, in-vitro, in-silico , pharmacogenomics, and pharmacogenetics. Nutrivigilance may be the greatest method to monitor herb-food interactions, but its adoption is limited worldwide., Conclusion: This article can serve as a lead for clinicians, guiding them regarding herb-drug, herb-food, and herb-herb interactions induced by commonly consumed plant species. Patients may also be counseled to avoid conventional drugs, botanicals, and foods with a restricted therapeutic window., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Warfarin is a popular anticoagulant with high global demand. However, studies have underlined serious safety issues when warfarin is consumed concomitantly with herbs or its formulations. This review aimed to highlight the mechanisms behind herb-warfarin interactions while laying special emphasis on its PKPD interactions and evidence on Herb-Warfarin Interaction (HWI) with regards to three different scenarios, such as when warfarin is consumed with herbs, taken as foods or prescribed as medicine, or when used in special situations. A targeted literature methodology involving different scientific databases was adopted for acquiring information on the subject of HWIs. Results of the present study revealed some of the fatal consequences of HWI, including post-operative bleeding, thrombosis, subarachnoid hemorrhage, and subdural hematomas occurring as a result of interactions between warfarin and herbs or commonly associated food products from Hypericum perforatum, Zingiber officinale, Vaccinium oxycoccos, Citrus paradisi , and Punica granatum . In terms of PK-PD parameters, herbs, such as Coptis chinensis Franch. and Phellodendron amurense Rupr., were found to compete with warfarin for binding with plasma proteins, leading to an increase in free warfarin levels in the bloodstream, resulting in its augmented antithrombic effect. Besides, HWIs were also found to decrease International Normalised Ratio (INR) levels following the consumption of Persea americana or avocado. Therefore, there is an urgent need for an up-to-date interaction database to educate patients and healthcare providers on these interactions, besides promoting the adoption of novel technologies, such as natural language processing, by healthcare professionals to guide them in making informed decisions to avoid HWIs., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

A number of journal articles written by researchers claiming Tinospora cordifolia (Giloy) is to blame for liver damage have sparked a wide range of debates between Ayush and the allopathic medical community, particularly in India. Some even argue that promoting Giloy-based formulations to the general public is a bad idea. In this backdrop, the purpose of this essay is to provide a counter-narrative based on some of the major gaps in the research that implicated Giloy in Drug-induced Liver Injury (DILI). Time-tested herb, Giloy, which has been used for pharmacological benefits since antiquity, as well as clinical and toxicological evidence suggest that Giloy is safe, and the observed negative effects can be attributed to Tinospora crispa , a herb that resembles Tinospora cordifolia in appearance. Holding Giloy species to be detrimental is unjustifiable unless other variables such as authentication, standardization, Good Agricultural and Collection Practices (GACP), Good Manufacturing Practices (GMP), regularization of the market are considered. This article emphasizes the importance of strategic collaboration between plants and contemporary medicine in order to eliminate concerns about the use of Giloy by the general public., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background: Non-steroidal Anti-Inflammatory Drugs (NSAIDs) are among the drugs that are most regularly administered to manage inflammation and pain. Over-the-Counter (OTC) NSAIDs are widely accessible, particularly in developing countries like India. This casual approach to using NSAIDs may operate as a magnet for NSAID-related adverse drug reactions (ADRs) among patients., Objectives: As patients in India are less informed about the appropriate use of NSAIDs and consumption patttern, adverse drug reactions, and the importance of reporting ADRs, the current study's objective is to promote patient safety by using pharmacovigilance as a tool to educate patients., Methods: A targeted literature methodology was utilized to gather the data pertaining to NSAIDs, their ADRs and their pharmacovigilance. Different scientific databases, such as Science Direct, PubMed, Wiley Online Library, Springer, and Google Scholar, along with authentic textbooks, were explored as reference literature., Results: In general, NSAIDs consumption pattern depends upon the different age groups. Around 1.6 billion tablets of NSAIDs are consumed in India for ailments, such as headaches, arthritis, menstrual cramps, osteoarthritis, back pain, rheumatoid arthritis, gout, osteoporosis, tendinitis, cancer pain and chronic pain. Common ADRs of NSAIDs include nausea, vomiting, headache, gastritis, abdominal pain, and diarrhoea. Also, they can cause renal damage and cardiovascular problems if not consumed in a dose-dependent manner. However, Diclofenac and Ibuprofen have both been linked to depression and dementia. There have been reports of aplastic anaemia, agranulocytosis linked to phenylbutazone, Stevens-Johnson, and Lyell's syndrome linked to isoxicam and piroxicam, as well as the vulnerability of new-borns to Reye's syndrome after aspirin use. Lack of awareness, time constraints and unpredictability, poor training in ADRs identification, etc., are some of the reasons for the under-reporting of ADR of NSAIDs in India., Conclusion: In order to rationally prescribe NSAIDs, it is essential to be aware of probable ADR's and establish prescription guidelines. Prescribers' behaviour can be changed toward excellent prescribing practices by conducting routine prescription assessments dealing with NSAIDs and providing feedback. In the near future, it will be critical to strengthen ADR data management and expand the reach of pharmacovigilance programs, ADR monitoring centers, and healthcare professionals' especially pharmacists' training in rural locations., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Farm animals are routinely subjected to painful husbandry procedures for various purposes. Goat kids are disbudded to improve goat welfare and to ensure safety of other livestock, farm personnel, attending veterinarians and for various other production and managemental procedures. Disbudding is commonly performed on dairy goat farms, in kids under 3 weeks of age. Many scientific studies reported physiological and behavioural changes indicating pain and distress following disbudding, and this can be a significant cause of welfare compromise in goat kids. Recognition and measurement of pain is important to treat and/or manage pain and distress following painful procedures. This review focuses on pain assessment in goat kids following disbudding, using both physiological and behavioural measures. As only a limited information is available on the topic of interest, relevant studies in other young farm animals have also been discussed to compare the status quo in goat kids.

Background: Consensus on the relative efficacy of available antihypertensive agents used in pregnancy is lacking., Objective: To compare treatment success with antihypertensives and categorize by route of administration., Search Strategy: MEDLINE, Embase, PubMed, Web of Science, Scopus, CINAHL, and clinicaltrials.gov were searched without date restriction., Data Collection: Peer-reviewed randomized controlled trials (RCTs) comparing pharmacologic agents used to treat hypertension in parturients were included. Evaluated treatment groups included IV-labetalol (BBIV), IV-hydralazine (DIV), oral-nifedipine (CCBPO), sublingual nifedipine (CCBSL), IV-calcium channel blocker (nonspecific)(CCBIV), IV-nitroglycerine (NTG), epoprostenol infusion (PRO), IV-ketanserin (5HT2B), IV-diazoxide (BZO), oral-nifedipine + methyldopa (CCBAG), oral-methyl-dopa (AAG), and oral prazosin (ABPO)., Analysis: Seventy-four studies (8324 patients) were eligible post PRISMA guidelines screening. Results were pooled using a Bayesian-approach for success of treatment (study defined target blood pressure), time to achieve target pressure, and neonatal intensive-care admissions., Results: Treatment success (primary outcome, 55 trials with 5518 patients) was analyzed. Surface under the cumulative ranking curve (SUCRA) was categorized for 13 drugs, CCBPO (0.84) followed by CCBSL (0.78) were most likely to be effective in achieving target blood pressure. After sub-grouping by presence/absence of preeclampsia, CCB-PO ranked highest for both [(0.82) vs. (0.77), respectively]. Serotonin antagonists (0.99) and nitroglycerin (0.88) ranked highest for time to target pressure. NICU admissions were lowest for alpha-2 agonists (0.89), followed by BB PO (0.82) and hydralazine IV (0.49)., Conclusion: Oral calcium-channel blockers ranked highest for treatment success. Ketanserin achieved target blood pressure fastest, warranting additional research. The results should be interpreted with caution as SUCRA values may not indicate whether the differences between interventions have clinically meaningful effect sizes., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier B.V.)

Objectives: Various approaches to quadratus lumborum block (QLB) have been found to be an effective analgesic modality after cesarean delivery (CD). However, the evidence for the superiority of any individual approach still needs to be demonstrated. Therefore, we conducted this network meta-analysis to compare and rank the different injection sites for QLB for pain-related outcomes after CD., Materials and Methods: PubMed, EMBASE, SCOPUS, and the Cochrane Central Registers of Controlled Trials (CENTRAL) were searched for randomized controlled trials (RCTs) evaluating the role of any approach of QLB with placebo/no block for post-CD pain. The primary outcome was parenteral consumption of morphine milligram equivalents in 24 postoperative hours. The secondary end points were early pain scores (4 to 6 h), late pain scores (24 h), adverse effects, and block-related complications. We used the surface under cumulative ranking probabilities to order approaches. The analysis was performed using Bayesian statistics (random-effects model)., Results: Thirteen trials enrolling 890 patients were included. The surface under cumulative ranking probability for parenteral morphine equivalent consumption in 24 hours was the highest (87%) for the lateral approach, followed by the posterior and anterior approaches. The probability of reducing pain scores at all intervals was highest with the anterior approach. The anterior approach also ranked high for postoperative nausea and vomiting reduction, the only consistent reported side effect., Discussion: The anterior approach QLB had a superior probability for most patient-centric outcomes for patients undergoing CD. The findings should be confirmed through large RCTs., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

For the past decades, gene editing demonstrated the potential to attenuate each of the root causes of genetic, infectious, immune, cancerous, and degenerative disorders. More recently, Clustered Regularly Interspaced Short Palindromic Repeats-CRISPR-associated protein 9 (CRISPR-Cas9) editing proved effective for editing genomic, cancerous, or microbial DNA to limit disease onset or spread. However, the strategies to deliver CRISPR-Cas9 cargos and elicit protective immune responses requires safe delivery to disease targeted cells and tissues. While viral vector-based systems and viral particles demonstrate high efficiency and stable transgene expression, each are limited in their packaging capacities and secondary untoward immune responses. In contrast, the nonviral vector lipid nanoparticles were successfully used for as vaccine and therapeutic deliverables. Herein, we highlight each available gene delivery systems for treating and preventing a broad range of infectious, inflammatory, genetic, and degenerative diseases. STATEMENT OF SIGNIFICANCE: CRISPR-Cas9 gene editing for disease treatment and prevention is an emerging field that can change the outcome of many chronic debilitating disorders., Competing Interests: Declaration of competing interest The authors have no known competing financial interests or personal relationships that would have influence what is reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Oxidative stress is a deteriorating condition that arises due to an imbalance between the reactive oxygen species and the antioxidant system or defense of the body. The key reasons for the development of such conditions are malfunctioning of various cell organelles, such as mitochondria, endoplasmic reticulum, and Golgi complex, as well as physical and mental disturbances. The nervous system has a relatively high utilization of oxygen, thus making it particularly vulnerable to oxidative stress, which eventually leads to neuronal atrophy and death. This advances the development of neuroinflammation and neurodegeneration-associated disorders such as Alzheimer's disease, Parkinson's disease, epilepsy, dementia, and other memory disorders. It is imperative to treat such conditions as early as possible before they worsen and progress to irreversible damage. Oxidative damage can be negated by two mechanisms: improving the cellular defense system or providing exogenous antioxidants. Natural antioxidants can normally handle such oxidative stress, but they have limited efficacy. The valuable features of nanoparticles and/or nanomaterials, in combination with antioxidant features, offer innovative nanotheranostic tools as potential therapeutic modalities. Hence, this review aims to represent novel therapeutic approaches like utilizing nanoparticles with antioxidant properties and nanotheranostics as delivery systems for potential therapeutic applications in various neuroinflammation- and neurodegeneration-associated disease conditions.

Background: Neuraxial opioids provide effective analgesia for Caesarean delivery, however, pruritus can be a troubling side-effect. Effective agents to prevent pruritus are needed. Our objective was to perform an updated systematic review and network meta-analysis to provide clinicians with a comparison of relative efficacy of available interventions to reduce the incidence of pruritus, induced by either intrathecal or epidural single-shot morphine, in women undergoing Caesarean delivery., Methods: Databases systematically searched (up to January 2022) included PubMed MEDLINE, Web of Science, EBSCO CINAHL, Embase, LILACS, and two Cochrane databases. We included randomised, controlled trials involving adult female patients undergoing Caesarean delivery. We pooled trials comparing interventions used for preventing pruritus after Caesarean delivery and performed a Bayesian model network meta-analysis., Results: The final primary network included data from comparisons of 14 distinct interventions (including placebo) used to reduce the incidence of pruritus in 6185 participants. We judged five interventions to be 'definitely superior' to placebo: propofol, opioid agonist-antagonists (neuraxial), opioid antagonists, opioid agonist-antagonists (systemic), and serotonin antagonists. For the network evaluating the incidence of severe pruritus (warranting additional therapeutic treatment of pruritus), data were available for 14 interventions (including placebo) in 4489 patients. For this outcome, we judged three interventions to be 'definitely superior' to placebo: dopamine antagonists (neuraxial) and systemic and neuraxial opioid agonist-antagonists., Conclusion: Our analysis found several interventions to be effective in reducing the incidence of pruritus. Although sub-hypnotic doses of propofol appear to have an antipruritic effect, replication of this finding and further investigation of optimal dosing are warranted., Systematic Review Protocol: PROSPERO (CRD42022367058)., (Copyright © 2023 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Cerebral autoregulation impairment is a critical aspect of subarachnoid hemorrhage (SAH)-induced secondary brain injury and is also shown to be an independent predictor of delayed cerebral ischemia (DCI) and poor neurologic outcomes. Interestingly, intraoperative hemodynamic and ventilatory parameters were shown to influence patient outcomes after SAH. The aim of the current study was to evaluate the association of intraoperative hypotension and hypocapnia with the occurrence of angiographic vasospasm, DCI, and neurologic outcomes at discharge. Intraoperative data were collected for 390 patients with aneurysmal SAH who underwent general anesthesia for aneurysm clipping or coiling between January 2010 and May 2018. We measured the mean intraoperative blood pressure and end-tidal carbon dioxide (ETCO 2 ), as well as the area under the curve (AUC) for the burden of hypotension: SBP below 100 or MBP below 65 and hypocapnia (ETCO 2 < 30), during the intraoperative period. The outcome measures were angiographic vasospasm, DCI, and the neurologic outcomes at discharge as measured by the modified Rankin scale score (an mRS of 0-2 is a good outcome, and 3-6 is a poor outcome). Univariate and logistic regression analyses were performed to evaluate whether blood pressure (BP) and ETCO 2 variables were independently associated with outcome measures. Out of 390 patients, 132 (34%) developed moderate-to-severe vasospasm, 114 (29%) developed DCI, and 46% (169) had good neurologic outcomes at discharge. None of the measured intraoperative BP and ETCO 2 variables were associated with angiographic vasospasm, DCI, or poor neurologic outcomes. Our study did not identify an independent association between the degree of intraoperative hypotension or hypocapnia in relation to angiographic vasospasm, DCI, or the neurologic outcomes at discharge in SAH patients.

Purpose: A protocol was developed to evaluate the value of an NK-1 receptor antagonist for preventing nausea and vomiting resulting from highly emetogenic chemotherapy when an olanzapine-based antiemetogenic regimen was used., Materials and Methods: A221602, a prospective double-blind, placebo-controlled clinical trial, was developed to compare 2 -olanzapine-containing antiemetic regimens, one with an NK-1 receptor antagonist (aprepitant or fosaprepitant) and one without. Trial patients had a malignant disease for which they received intravenous highly emetogenic chemotherapy (single day cisplatin ≥ 70 mg/m2 or doxorubicin plus cyclophosphamide on 1 day). Patients on both arms received commonly administered doses of a 5-HT3 receptor antagonist, dexamethasone, and olanzapine. Additionally, patients were randomized to receive an NK-1 receptor antagonist (fosaprepitant 150 mg IV or aprepitant 130 mg IV) or a corresponding placebo. The primary objective was to compare the proportion of patients with no nausea for 5 days following chemotherapy between the 2 study arms. This trial was designed to test for the noninferiority of deleting the NK-1 receptor antagonist, with noninferiority defined as a decrease in freedom from nausea by less than 10%., Results: A total of 690 patients were entered on this trial, 50% on each arm. The proportion of patients without nausea for the complete 5-day study period was 7.4% lower (upper limit of the one-sided 95% confidence interval was 13.5%) in the arm without an NK-1 receptor antagonist compared with the arm with an NK-1 receptor antagonist., Conclusion: This trial did not provide sufficient evidence to support that deletion of the NK-1 receptor antagonist was as good as keeping it, as a part of a 4-drug antiemetic regimen for highly emetogenic chemotherapy (ClinicalTrials.gov Identifier: NCT03578081)., (© The Author(s) 2023. Published by Oxford University Press.)

Ethnopharmacological Relevance: The use of herbal medicines for prophylaxis, prevention, and treatment of various ailments is rising throughout the world because they are thought to be safer than allopathic treatments, which they are. However, several investigations have documented the toxicity and adverse drug reactions (ADR) of certain formulations and botanicals if not consumed wisely., Aim of the Study: The goal of the current study is to address herbal medication pharmacovigilance (PV) modeling and related considerations for improved patient safety. Also, focus is laid on the comprehensive and critical analysis of the current state of PV for herbal medications at the national and international levels., Materials and Methods: Targeted review also known as focused literature review methodology was utilized for exploring the data from various scientific platforms such as Science Direct, Wiley Online Library, Springer, PubMed, Google Scholar using "pharmacovigilance, herbal medicine, traditional medicine, ADR, under reporting, herb toxicity, herb interactions" as keywords along with standard literature pertaining to herbal medicines that is published by the WHO and other international and national organizations etc. The botanical names mentioned in the present article were authenticated using World Flora Online database., Results: The historical developments paving the way for PV in regulatory setup were also discussed, along with various criteria's for monitoring herbal medicine, ADR of herbs, phytoconstituents, and traditional medicines, herb-drug interactions, modes of reporting ADR, databases for reporting ADR's, provisions of PV in regulatory framework of different nations, challenges and way forward in PV are discussed in detail advocating a robust drug safety ecosystem for herbal medicines., Conclusion: Despite recent efforts to encourage the reporting of suspected ADRs linked to herbal medicines, such as expanding the programme and adding community pharmacists and other healthcare professionals as recognized reporters, the number of herbal ADR reports received by the regulatory bodies remains comparatively low. Since users often do not seek professional advice or report if they have side effects, under-reporting, is anticipated to be significant for herbal medications. There are inadequate quality control methods, poor regulatory oversight considering herbs used in food and botanicals, and unregulated distribution channels. In addition, botanical identity, traceability of herbs, ecological concerns, over-the-counter (OTC) herbal medicines, patient-physicians barriers requires special focus by the regulatory bodies for improved global safety of herbal medicines., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background Context: Metals from spinal implants are released into surrounding tissues by various mechanisms. Metal ion release has been associated with clinical implant failure, osteolysis, and remote site accumulation with adverse events. Significant corrosion and associated metal ion release has been described with currently used spinal implant alloys. A novel metal alloy, Molybdenum-47.5Rhenium alloy (MoRe®), was approved for use in medical implants in 2019 by the FDA., Purpose: To evaluate the metal ion release profile of MoRe alloy after immersion in both a stable physiologic, as well as in an inflammatory environment., Study Design: In vitro study., Methods: The ion release profile of the MoRe alloy was comprehensively evaluated in-vitro after prolonged immersion in physiologic and inflammatory environments. Ion concentration analyses were then conducted using inductively coupled plasma-mass spectrometry (ICP-MS) methods. Comparative testing of titanium (Ti-6Al-4V) and cobalt chromium (Co-28Cr-6Mo) was also performed., Results: Under baseline physiologic conditions, the MoRe alloy demonstrates very low molybdenum and rhenium ion release rates throughout the 30-day test period. During the first time interval (day 0-1), low levels of molybdenum and rhenium ions are detected (<0.3 μg/cm 2 day) followed by a rapid reduction in the ion release rates to <0.05 μg/cm 2 day during the second time interval (days 1-3) followed by a further reduction to very low steady-state rates <0.01 μg/cm 2 day during the third time interval (days 3-7), which were maintained through 30 days. In the inflammatory condition (H 2 O 2 solution), there was a transient increase in the release of molybdenum and rhenium ions, followed by a return to baseline ion release rates (days 2-4), with a further reduction to low steady-state rates of ∼0.01 μg/cm 2 day (days 4-8). The measured molybdenum and rhenium ion release rates in both steady state (<0.01 μg/cm 2 day), and inflammatory environments (0.01 μg/cm 2 day) were far below the established FDA-permitted daily exposure (PDE) of 1,900 μg/cm 2 day for molybdenum and 4,400 μg/cm 2 day for rhenium. In contrast, titanium and cobalt chromium approached or exceeded their established PDE values in an inflammatory environment., Conclusions: The novel biomaterial MoRe demonstrated a lower metal ion release profile in both a physiologic and inflammatory environment and was well below the established PDE.  Comparative testing of the cobalt-chromium and titanium alloys found higher levels of ion release in the inflammatory environment that exceeded the PDE for cobalt and vanadium., Competing Interests: Declarations of Competing Interests One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Patients suffering from psychiatric disorders face many difficulties due to their condition, medications and lifestyle. Oral health and nutrition may be affected, further complicating their lives. Our aim was to provide in-depth information on oral health and nutritional factors in a small group of patients in short-term psychiatric ward., Methods: Twenty-three patients (mean age 36, average medications five) were recruited during short-term hospitalization in a psychiatric ward. Inclusion criteria: anxiety, psychosis and/or depression, and use of at least one antidepressant or anxiolytic/antipsychotic drug with xerostomia as a known side effect. Subjective oral dryness was evaluated using the Shortened Xerostomia Inventory (SXI). Oral examination included Clinical Oral Dryness Score (CODS), secretion of unstimulated (UWS) and stimulated whole saliva (SWS), and evaluation of dental, gingival, and periodontal status. Self-reported complaints of oral disorders were recorded. The Oral Health Impact Profile-14 (OHIP-14) was used to explore oral health-related quality of life. Nutritional status was assessed using the Patient-Generated Subjective Global Assessment Short Form (PG-SGA-SF), and diet quality was assessed using the Mediterranean diet score (KIDMED)., Results: Compared to healthy controls, the patients had significantly higher SXI scores and CODS, and SWS secretion was lower. Complaints of dysgeusia and halitosis were significantly more frequent among patients. Gingivitis was more common in patients. OHIP-14 scores were much higher in the patients, and they reported significantly poorer oral and general health. Most patients lacked a regular meal pattern. Very low diet quality was observed in five patients, while improvements were needed in twelve. " Dry mouth " and " No appetite, just did not feel like eating " were the most common symptoms preventing patients from eating enough. The PG-SGA-SF symptoms component score showed a strong negative correlation with self-reported oral health, and a strong positive correlation with OHIP-14., Conclusion: This relatively small group of patients in short-term psychiatric ward had both reduced oral health and poor oral health-related quality of life. Furthermore, their nutritional intake was affected by their oral health problems. Although larger groups need to be studied, these findings indicate that oral health and nutrition should be evaluated and adjusted in these patients to improve their overall care., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Frigaard, Hynne, Randsborg, Mellin-Olsen, Young, Rykke, Singh, Hove, Hofgaard and Jensen.)

Background and Aims: Ensuring safe central venous catheter tip placement is important. Multiple techniques are available to estimate the length of catheter insertion for subclavian and internal jugular approaches. However, the methods to determine the length of insertion for the axillary route have not been validated. The purpose of this feasibility study was to evaluate a simple method for the calculation of catheter length to be inserted and assess whether it accurately predicts the correct tip placement., Material and Methods: A total of 102 patients requiring preoperative central venous cannulation were evaluated, out of which 60 had successful axillary vein (AxV) cannulation. The length of insertion was calculated using the formula: (2/3* A + B) +Y (A: Clavicular length on chest radiograph [CXR], B: Vertical distance between the sternal head and carina on CXR, Y: Perpendicular distance from the skin to the AxV on ultrasound). A postoperative CXR was used to assess the accurate tip placement (2 cm above the carina to 0.5 cm below it). The primary outcome of the study was the rate of successful placement of the central venous catheter (CVC) in terms of the correct position of the tip of the catheter when the length of the catheter inserted was predicted by the formula described previously., Results: Optimal placement was observed in 83.33% of the cases. A higher rate of accuracy was seen in the females ( P value = 0.03) and shorter patients ( P value = 0.01). A Bland-Altman plot depicted a high degree of agreement., Conclusion: Use of the formula using a CXR and ultrasound allowed P successful placement of the CVC tip at the desired location in 83.33% of the cases., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Anaesthesiology Clinical Pharmacology.)

Background and Aims: The use of sugammadex instead of neostigmine for the reversal of neuromuscular blockade may decrease postoperative pulmonary complications. It is unclear if this finding is applicable to situations where sugammadex is administered after the administration of neostigmine. The objective of this study was to compare the incidence of a composite outcome measure of major postoperative pulmonary complications in patients who received sugammadex as a rescue agent after neostigmine versus those who received sugammadex alone for reversal of neuromuscular blockade., Material and Methods: This retrospective cohort study analyzed the medical records of adult patients who underwent elective inpatient noncardiac surgery under general anesthesia and received sugammadex for reversal of neuromuscular blockade, at a tertiary care academic hospital between August 2016 and November 2018., Results: A total of 1,672 patients were included, of whom 1,452 underwent reversal with sugammadex alone and 220 received sugammadex following reversal with neostigmine/glycopyrrolate. The composite primary outcome was diagnosed in 60 (3.6%) patients. Comparing these two groups, and after adjusting for confounding factors, patients who received sugammadex after reversal with neostigmine had more postoperative pulmonary complications than those reversed with sugammadex alone (6.8% vs. 3.1%, odds ratio, 2.29; 95% confidence interval [CI], 1.25 to 4.18; P = 0.006)., Conclusion: The use of sugammadex following reversal with neostigmine was associated with a higher incidence of postoperative pulmonary complications as compared to the use of sugammadex alone. The implications of using sugammadex after the failure of standard reversal drugs should be investigated in prospective studies., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Anaesthesiology Clinical Pharmacology.)

There is conflicting evidence regarding the analgaesic efficacy of single-shot serratus anterior plane block (SAP) for breast surgery. This meta-analysis aimed to evaluate the analgaesic efficacy of SAP compared with non-block care (NBC) and other regional blocks, i.e. paravertebral block (PVB) and modified pectoral nerve block (PECS block) for breast surgery. PubMed, Embase, Scopus, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov were searched. We included randomized controlled trials reporting the use of the SAP block in adult breast surgery. The primary outcome was postoperative oral morphine equivalent (OME) consumption for up to 24 hours. Random-effects models were used to pool results and mean difference (MD), and odds ratio (OR) was calculated for continuous and dichotomous outcomes, respectively. GRADE guidelines were used to evaluate the strength of evidence, and trial sequential analysis (TSA) was performed to provide certainty to the conclusion. Twenty-four trials enrolling 1789 patients were included. Moderate strength evidence suggested that SAP provided a significant reduction in 24-hour OME compared with NBC [MD - 24.9 mg (95% CI - 41.54, -8.25; P < 0.001, I 2 = 99.68%)]. TSA ruled out the possibility of false-positive results. Subgroup analysis for the SAP demonstrated that the superficial plane approach was more effective in reducing opioid consumption than the deep approach. The odds of developing PONV were significantly lower in SAP compared to NBC. Compared with PVB and PECS, SAP block was not statistically different for 24-hour OME and time to first rescue analgaesia. Single-shot SAP reduced opioid consumption, prolonged analgaesia duration, lowered pain scores, and decreased the incidence of PONV compared to NBC. There was no statistically significant difference in the studied endpoints between SAP, PVB, and PECS blocks., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Indian Journal of Anaesthesia.)

One of the main concerns of intraoperative hypotension is adequacy of cerebral perfusion, as cerebral blood flow decreases passively when mean arterial pressure falls below the lower limit of cerebral autoregulation. Treatment of intraoperative hypotension includes administration of drugs, such as inotropes and vasopressors, which have different pharmacological effects on cerebral hemodynamics; there is no consensus on the preferred drug to use. We performed a network meta-analysis (NMA) to pool and analyze data comparing the effect on cerebral oxygen saturation (ScO 2 ) measured by cerebral oximetry of various inotropes/vasopressors used to treat intraoperative hypotension. We searched randomized control trials in Embase, Ovid Medline, Scopus, Cochrane Central Register of Controlled Trials, and Web of Science. We included studies that enrolled adult patients undergoing surgery under general/spinal anesthesia that compared at least 2 inotropes/vasopressors to treat hypotension. We reviewed 51 full-text manuscripts and included 9 randomized controlled trials in our study. The primary outcome was change in ScO 2 . Our results showed the likelihood that dopamine, ephedrine, and norepinephrine had the lowest probability of decreasing ScO 2 . The suggested rank order to maintain ScO 2 , from higher to lower, was dopamine

Introduction: Postpartum depression has costly consequences for the mother, baby, and society. Numerous pharmacological and non-pharmacological interventions are available for the prevention and treatment of postpartum depression. To date, no attempt has been made to synthesize the evidence from comparisons of interventions both within and across these categories., Methods: We will perform a systematic review of the literature and perform network meta-analysis of interventions to (a) prevent and (b) treat postpartum depression. This review will include studies of primiparous or multiparous women during pregnancy or within 12 months of delivery of their baby that assess either interventions initiated during pregnancy or within 1 year of childbirth. Comparators will be other eligible interventions or control conditions. The outcome of interests will be related to the antidepressant efficacy of the interventions as well as their acceptability. The published literature will be searched in Ovid MEDLINE 1946-, Embase.com 1947-, Scopus 1823-, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. The search will use a combination of standardized terms and keywords for postpartum depression, a sensitive search filter to limit for randomized controlled trials, and a librarian-created "humans" filter. The search results will be uploaded to the Covidence online systematic review platform (Veritas Health Information Ltd., Victoria, Australia) where two review team members will independently screen articles. We will extract data to include year of publication, language, country, participants (number, demographic data, eligibility criteria, psychiatric symptoms, and co-morbidities), characteristics of the intervention and control conditions, and reported outcomes. Risk of bias for each study will be assessed independently by two review authors using the RoB 2: A revised Cochrane risk of bias tool for randomized trials. Network meta-analysis will be performed using a Bayesian hierarchical model supplemented with a Markov chain Monte Carlo approach., Discussion: Postpartum depression is a devastating disease with long-lasting consequences. Given the numerous available interventions to both prevent and treat postpartum depression and the great number of studies comparing them, it is imperative that clinicians and patients are provided with an assessment of their comparative efficacy and acceptability., Systematic Review Registration: Prospero registration (CRD42022303247)., (© 2022. The Author(s).)

Local anesthetics are commonly used in farm animals to provide analgesia for painful procedures but can cause adverse effects at high systemic concentrations. The pharmacokinetics and efficacy of a long-acting sucrose acetate isobutyrate (SAIB) bupivacaine formulation following cornual nerve block in calves were compared to lidocaine. Fourteen calves were randomly assigned to one of the treatment groups (i) 5% Bupivacaine-SAIB (BUP-SAIB), n = 7; or (ii) 2% lidocaine (LID), n = 7. Cornual nerve block was performed, and duration of effective analgesia was evaluated by nociceptive threshold testing using a hand-held pressure algometer. Blood samples were collected at various time points and plasma concentrations were analyzed by HPLC. Pharmacokinetic parameters were calculated using a non-compartmental model. The mechanical nociceptive thresholds showed that the novel formulation could desensitize the skin around the horn bud for 18.77 ± 8.88 h (range 8-36 h), compared to 0.79 ± 0.34 h (range 0.5-1.5 h) with lidocaine. The mean maximum plasma concentration (C max ) of bupivacaine was 152.03 (SD 37.34) ng/mL and its T max was 0.39 (SD 0.13) h. The half-life of elimination was 32.79 ± 11.00 h and the rate of clearance was 0.12 ± 0.03 L h -1 . No toxicity signs were seen after treatment in either group. The novel formulation produced long-lasting analgesia of several times greater duration than that produced by lidocaine. This study showed that the safety and efficacy of the SAIB formulation justifies further studies in a larger population of animals., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Venkatachalam, Kells, Chambers, Jacob, Ward and Singh.)

Background: Evidence suggests ketamine may prevent postpartum depression (PPD) after cesarean delivery (CD) although intolerability and inconvenience of administration are problematic. We assessed the feasibility of studying ketamine (0.5 mg/kg, via subcutaneous injection or 40-min intravenous infusion) to prevent PPD after CD., Methods: Twenty-three women scheduled for cesarean delivery under neuraxial anesthesia were randomized to one of three groups: subcutaneous ketamine (SC Group, n = 8), intravenous ketamine (IV Group, n = 8) or placebo (n = 7). We measured depression (Edinburgh Postpartum Depression Scale [EPDS]) scores pre-operatively and at 1, 2, 21 and 42 days postoperatively. Anxiety, adverse effects, surgical site pain and analgesic consumption were also assessed. Feasibility was assessed based on acceptability, burden of disease, ability to collect study data and, tolerability of interventions., Results: Baseline characteristics of groups were similar, however, more women in the placebo group had pre-existing anxiety disorder (p = 0.03). 20.7% (25/121) of those approached consented to participate and 34.8% (8/23), of those assessed, screened positive for depression in the postpartum (EPDS > 12). PPD screening data was complete in 78.3% (18/23). No differences were observed for any adverse effect outcomes except for fewer incidences of intraoperative shivering with ketamine (SC: 25%, IV: 0% and Placebo: 85.7%, p = 0.01). No statistically significant difference in positive screening for PPD was observed (SC: 14.3%, IV: 50% and Placebo: 42.9%, p = 0.58)., Conclusion: An RCT was judged to be feasible and there was no evidence of intolerability of either route of ketamine administration. Dispensing with the need for intravenous access makes the subcutaneous route a particularly attractive option for use in the postpartum population. Further examination of these interventions to prevent, and possibly treat, postpartum depression is warranted., Trial Registration: NCT04227704, January 14 th , 2020., (© 2022. The Author(s).)

α, β-Arteether (ART) antimalarial drug is used to treat chloroquine-resistant malaria and cerebral malaria. The drug's solubility in water is relatively low (17 μg/mL), and 40% of the drug degrades in the stomach, resulting in poor bioavailability. This article discusses the quality by design technique used for formulation development and optimization of nanostructured lipid carriers (NLCs). The ART-NLCs were made by solvent diffusion method. To develop solid NLCs, the NLCs were freeze-dried and encapsulated in enteric-coated capsule shells. The prepared NLCs showed particle size ranging between 156.8 ± 12 nm while zeta potential ranging between - 26.1 ± 0.22 mV. They also showed high encapsulation efficiency (> 85%) and an amorphous drug's lipid matrix state. Pharmacokinetic parameters of optimized formulation enhance oral bioavailability to 18.45%. These investigations demonstrated the superiority of NLCs for improvement of solubility as well as oral bioavailability of poorly water-soluble drugs., (© 2022. The Author(s), under exclusive licence to American Association of Pharmaceutical Scientists.)

Objective: To study the use of serial ultrasound gastric residual volume (GRV) measurements in predicting feed intolerance in critically ill patients., Patients and Methods: This study was conducted in various intensive care units (ICUs) of All India Institute of Medical Sciences, New Delhi. Forty-three critically ill patients aged more than 18 years were studied for a total of 130 enteral feeding days. Gastric residual volume was obtained by calculating the antral cross-sectional area (CSA), which is the product of anteroposterior (AP) and craniocaudal (CC) diameters of gastric antrum obtained using ultrasound in the right lateral decubitus position. A baseline measurement was done before the initiation of the enteral feed and termed GRV0, the ultrasound scanning was repeated every 1 hour for the first 4 hours and termed GRV1, GRV2, GRV3, and GRV4, respectively, and the patients were watched for feed intolerance. The receiver operating characteristic (ROC) curves were constructed to correlate the GRV at each time with feed intolerance., Results: The data from 43 medical and surgical critically ill patients were analyzed. Out of 130 feeding days, 13 were noted to be feed intolerant. Gastric residual volume at the end of the fourth hour of feed, that is, GRV4 was the best predictor of feed intolerance with 99.3% area under the curve (AUROC), sensitivity of 99%, specificity of 99.3%, and 95% CI, 0.89-0.98 followed by GRV3, with AUROC of 96% and sensitivity and specificity of 92.3 and 96%, respectively, with 95% CI, 0.92-0.99., How to Cite This Article: Ankalagi B, Singh PM, Rewari V, Ramachandran R, Aggarwal R, Soni KD, et al . Serial Ultrasonographic-measurement of Gastric Residual Volume in Critically Ill Patients for Prediction of Gastric Tube Feed Intolerance. Indian J Crit Care Med 2022;26(9):987-992., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2022; The Author(s).)

Purpose: To investigate taste and smell function in survivors, with a minimum of 2 years since treatment of childhood medulloblastoma (MB)/central nervous system supratentorial primitive neuroectodermal tumor (CNS-PNET)., Methods: This cross-sectional study included 40 survivors treated ≤ 20 years of age. Taste strips with four concentrations of sweet, sour, salt, and bitter were used to assess taste function in all participants. Score from 0 to 16; ≥ 9 normogeusia, < 9 hypogeusia, and complete ageusia which equals no sensation. No sensation of a specific taste quality equals ageusia of that quality. Thirty-two participants conducted smell testing using three subtests of Sniffin' sticks: threshold, discrimination, and identification. Together they yield a TDI-score from 1 to 48; functional anosmia ≤ 16.00, hyposmia > 16.00- < 30.75, normosmia ≥ 30.75- < 41.50, and ≥ 41.50 hyperosmia. Results were compared with normative data. Survivors rated their taste and smell function using a numerical rating scale (NRS) score 0-10., Results: Forty survivors with a mean time since treatment of 20.5 years, 13 (32.5%) were diagnosed with hypogeusia, nine (22.5%) of these being ageusic to one or more taste qualities. Seventeen (53%) of 32 participants were diagnosed with hyposmia. The mean scores of the olfactory subtests, and TDI score were significantly lower than normative data (P < 0.0001). The mean NRS scores of smell and taste function were 7.9 ± 1.5 and 8 ± 1.3, respectively., Conclusion: Our study showed impaired taste and smell function in survivors of childhood MB/CNS-PNET using objective measurements. However, subjective ratings did not reflect objective findings., (© 2022. The Author(s).)

Background: Analgesic efficacy of intravenous dexamethasone has not been well defined after caesarean delivery. We performed a systematic review and meta-analysis to evaluate the impact of peri-operative dexamethasone administration on postoperative pain after caesarean delivery., Objectives: We investigated the impact of perioperative intravenous dexamethasone on postoperative pain after caesarean delivery. The two primary outcomes of interest were early (4 to 6 h) resting pain scores and time to first rescue analgesia., Design: A systematic review and meta-analysis of randomised controlled trials (RCTs)., Data Sources: PubMed, EMBASE, Scopus and the Cochrane central registers of controlled trials were searched to identify RCTs from inception to April 2021., Eligibility Criteria: Prospective RCTs comparing the role of intravenous dexamethasone with non-active control were eligible for inclusion. Exclusion criteria included trials comparing various doses of dexamethasone without any control treatment arm, dexamethasone with other active drugs and trials comparing different routes of dexamethasone, for example, wound infiltration., Results: Thirteen RCTs constituting of 988 parturients undergoing caesarean delivery were included. Patients receiving dexamethasone had lower pain scores at rest at 4 to 6 h after surgery, mean difference -1.29 [95% confidence interval (CI), -1.85 to -0.73], P < 0.0001, with low quality of evidence (I2 = 94%). Moderate quality of evidence (I2 = 17%) suggested that the time to first rescue analgesia in the dexamethasone group was significantly longer, mean difference 2.64 h (95% CI, 1.85 to 3.42), P  < 0.0001. Trial sequential analysis for pain scores suggested the benefit of dexamethasone; however, the requisite information size (RIS) could not be reached, whereas RIS was adequate for time to rescue analgesia. Significant reduction in pain scores at all times and opioid consumption at 24 h with dexamethasone were observed with sparse reporting on adverse effects., Conclusion: Peri-operative intravenous dexamethasone was associated with a significant decrease in postoperative pain scores at rest and a longer time to first rescue analgesia, along with a small but statistically significantly reduced opioid consumption after caesarean delivery compared with nonactive control., (Copyright © 2021 European Society of Anaesthesiology and Intensive Care. Unauthorized reproduction of this article is prohibited.)

Butorphanol and dexmedetomidine (DXM) can produce analgesia in birds. Intranasal (IN) route of drug administration is easier, and free of risks such as pain and tissue damage compared with intravenous, intramuscular or subcutaneous routes in bird species, including wild birds. Although previous studies have demonstrated the use of IN route for producing sedation, no studies are available on the pharmacokinetics and pharmacodynamics of IN drugs in birds. This study analyzed the pharmacokinetics and sedative-analgesic efficacy of intranasal butorphanol (2 mg/kg), dexmedetomidine (80 µg/kg) and their combination (butorphanol, 2 mg/kg; DXM, 80 µg/kg) in healthy, male, Ross broiler chickens ( n = 6/group) aged between 6 and 8 weeks. Maximum plasma concentration (Cmax, p = 0.01), area under the plasma concentration-time curve from time zero to 120 min (AUC 0 to 120 , p = 0.02) and apparent volume of distribution at steady state (Vss, p = 0.02) of DXM were significantly higher than that of DXM co-administered with butorphanol. The mechanical nociceptive thresholds and the sedation scores of DXM group were significantly higher than the baseline value. Dexmedetomidine (80 µg/kg, IN) was effective in chickens, and the drug absorption was more rapid than that of DXM with butorphanol. However, the duration of action of DXM was short. Lower value of Cmax and nociceptive thresholds showed the nonsignificant efficacy of butorphanol at a dose of 2 mg/kg after IN administration in broiler chickens.

Background: Postpartum hemorrhage causes a quarter of global maternal deaths. The World Health Organization recommends oxytocin as the first line agent to prevent hemorrhage during cesarean delivery. However, some randomized controlled trials suggest that other uterotonics are superior., Objective: We conducted a network meta-analysis comparing the ability of pharmacologic agents to reduce blood loss and minimize the need for additional uterotonics during cesarean delivery., Data Sources: We searched the Cochrane Central Register of Controlled Trials, Embase, and MEDLINE databases from inception to May 2020., Study Eligibility Criteria: We included randomized controlled trials that compared oxytocin, carbetocin, misoprostol, ergometrine, carboprost, or combinations of these in the prevention of postpartum hemorrhage during cesarean delivery., Methods: We performed a systematic review followed by an NMA in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quality of the evidence was assessed with the Confidence in Network Meta-Analysis approach and Grading of Recommendations, Assessment, Development and Evaluations tool within the summary of findings table. Our primary outcomes were the estimated blood loss and need for additional uterotonics. Secondary outcomes included nausea and postpartum hemorrhage of >1000 mL. We performed sensitivity analyses to explore the influence of surgical context and oxytocin administration strategy., Results: A total of 46 studies with 7368 participants were included. Of those, 21 trials (6 agents and 3665 participants) formed the "estimated blood loss" network and, considering the treatment effects, certainty in the evidence, and surface under the cumulative ranking curve scores, carbetocin was assessed to probably be superior to oxytocin, but only in reducing the estimated blood loss by a clinically insignificant volume (54.83 mL; 95% confidence interval, 26.48-143.78). Misoprostol, ergometrine, and the combination of oxytocin and ergometrine were assessed to probably be inferior, whereas the combination of oxytocin and misoprostol was assessed to definitely be inferior to oxytocin. A total of 37 trials (8 agents and 6193 participants) formed the "additional uterotonic" network and, again, carbetocin was assessed to probably be superior to oxytocin, requiring additional uterotonics 185 (95% confidence interval, 130-218) fewer times per 1000 cases. Oxytocin plus misoprostol, oxytocin plus ergometrine, and misoprostol were assessed to probably be inferior, whereas carboprost, ergometrine, and the placebo were definitely inferior to oxytocin. For both primary outcomes, oxytocin administration strategies had a higher probability of being the best uterotonic, if initiated as a bolus., Conclusion: Carbetocin is probably the most effective agent in reducing blood loss and the need for additional uterotonics. Oxytocin appears to be more effective when initiated as a bolus., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Lactate as a target for resuscitation in patients with septic shock has important limitations. The PcvCO 2 -PaCO 2 /CaO 2 -CcvO 2 ratio may be used as an alternative for the same. The primary outcome of the study is to evaluate the correlation between serum lactate and PcvCO 2 -PaCO 2 /CaO 2 -CcvO 2 ratio measured at various time points to a maximum of 24 hours in patients with septic shock [mean arterial pressure (MAP) <65 mm Hg]. The secondary outcomes were to study the (1) relationship between the PcvCO 2 -PaCO 2 /CaO 2 -CcvO 2 ratio and lactate clearance at 6, 12, and 24 hours as compared to the initial serum lactate, (2) to ascertain whether the PcvCO 2 -PaCO 2 /CaO 2 -CcvO 2 ratio and the arterial lactate levels in the first 24 hours are able to predict mortality at day 28 of enrollment, and (3) to determine whether the PcvCO 2 -PaCO 2 / CaO 2 -CcvO 2 ratio and arterial lactate are useful in discriminating survivors from nonsurvivors., Materials and Methods: Thirty patients with sepsis-induced hypotension who were being actively resuscitated were enrolled. Paired arterial and central venous blood samples were obtained 0.5 hourly till stabilization of MAP and 6 hourly thereafter for the first 24 hours. Patients were followed up to day 28 of enrollment for mortality and organ system failure., Results: A positive correlation was observed between arterial lactate and PcvCO 2 -PaCO 2 /CaO 2 -CcvO 2 ratio at 0, 6, 12, and 18 hours ( R = 0.413, p = 0.02; R = 0.567, p = 0.001; R = 0.408, p = 0.025; R = 0.521, p = 0.003, respectively). No correlation was seen between PcvCO 2 -PaCO 2 /CaO 2 -CcvO 2 ratio and lactate clearance. The subgroup analysis showed that PcvCO 2 -PaCO 2 /CaO 2 -CcvO 2 ratio >1.696 at 24 hours of resuscitation predicted 28-day mortality (sensitivity: 80%, specificity 69.2%, area under the receiver operating characteristic curve 0.82)., Conclusion: The PcvCO 2 -PaCO 2 /CaO 2 -CcvO 2 ratio and lactate are positively correlated during the first 24 hours of active resuscitation from sepsis-induced hypotension, and a threshold of 1.696 mm Hg/mL/dL at 24 hours significantly differentiates survivors from nonsurvivors (CTRI/2017/11/010342)., How to Cite This Article: Madabhushi S, Trikha A, Anand RK, Ramachandran R, Singh PM, Rewari V. Temporal Evolution of the PcvCO 2 -PaCO 2 /CaO 2 -CcvO 2 Ratio vs Serum Lactate during Resuscitation in Septic Shock. Indian J Crit Care Med 2021; 25(12):1370-1376., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2021; Jaypee Brothers Medical Publishers (P) Ltd.)

Background: Fascia iliaca block (FICB) has been used to reduce pain and its impact on geriatric patients with hip fractures., Objective: We conducted this meta-analysis to investigate the analgesic efficacy of this block in comparison to standard of care (SOC) when performed by non-anesthesiologist in the emergency department., Methods: Search on PubMed, SCOPUS, EMBASE, Google Scholar and Cochrane database for randomized and quasi-randomized trials were performed. The primary outcome was to compare pain relief at rest at 2-4 h. The pain relief at various time intervals, reduction in opioid use, the incidence of nausea/ vomiting, delirium and length of hospital stay were the secondary outcomes studied. Trial Sequential Analysis (TSA) was performed for the primary outcome., Results: Eleven trials comprising 895 patients were included in the meta-analysis. Patients receiving FICB had significant better pain relief at rest at 2-4 h with mean difference of 1.59 (95% CI, 0.59-2.59, p = 0.002) with I 2  = 96%. However, the certainty of the evidence was low and TSA showed that the sample size could not reach the requisite information size. A significant difference in pain relief at rest and on movement started within 30 min and lasted till 4 h of the block. Use of FICB was associated with a significant reduction in post-procedure parenteral opioid consumption, nausea and vomiting and length of hospital stay., Conclusions: FICB is associated with significant pain relief both at rest and on movement lasting up to 4 h as well as a reduction in opioid requirement and associated nausea and vomiting in geriatric patients with hip fracture. However, the quality of evidence is low and additional trials are necessary., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Vasospasm and delayed ischemic neurologic deficits are the leading causes of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Several therapeutic agents have been assessed in randomized controlled trials for their efficacy in reducing the incidence of vasospasm and improving functional outcome. The aim of this network meta-analysis is to compare all these therapeutic agents for their effect on functional outcome and other parameters after aSAH., Methods: A comprehensive search of different databases was performed to retrieve randomized controlled trials describing the effect of various therapeutic approaches on functional outcome and other parameters after aSAH., Results: Ninety-two articles were selected for full text review and 57 articles were selected for the final analysis. Nicardipine prolonged-release implants were found to be the best treatment in terms of favorable outcome (odds ratio [OR], 8.55; 95% credible interval [CrI], 1.63-56.71), decreasing mortality (OR, 0.08; 95% CrI, 0-0.82), and preventing angiographic vasospasm (OR, 0.018; 95% CrI, 0.00057-0.16). Cilostazol was found to be the second-best treatment in improving favorable outcomes (OR, 3.58; 95% CrI, 1.97-6.57) and decreasing mortality (OR, 0.41; 95% CrI, 0.12-1.15). Fasudil (OR, 0.16; 95% CrI, 0.03-0.78) was found to be the best treatment in decreasing increased vessel velocity and enoxaparin (OR, 0.25; 95% CrI, 0.057-1.0) in preventing delayed ischemic neurologic deficits., Conclusions: Our analysis showed that nicardipine prolonged-release implants and cilostazol were associated with the best chance of improving favorable outcome and mortality in patients with aSAH. However, larger multicentric studies from other parts of the world are required to confirm these findings., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: There was significant surge in the academic publications after the onset of COVID-19 outbreak. The aim of this study was to scientometrically analyze all the medical publications on COVID-19 in 2020 as well as the top 100 cited articles., Evidence Acquisition: We performed a search of the "Web of Science" database using the keywords "COVID," and "corona" on December 20, 2020., Evidence Synthesis: Our search retrieved a total of 45,420 articles on the topic COVID-19 in the year 2020. Corresponding authors from 143 countries contributed to these articles. The highest number of articles were contributed by corresponding authors from the USA (N.=10299), whereas 50 articles in the top 100 cited articles had corresponding authors from China. Among the top 100 cited, the majority were published from Huazhong University of Science and Technology in China (N.=37). New England Journal of Medicine had the maximum impact (h-index of 57), closely followed by Lancet (h-index=55)., Conclusions: Scientific publications amount on COVID-19 disease grew at an astonishing pace during 2020. We caution the readers that this rapidity of publication could have missed out on the rigorous review process and the scientific basis of the methods followed.

Persistent tachycardia in patients with septic shock predicts poor outcome. This study sought to investigate the effect of the cardiac pacemaker current inhibitor ivabradine on heart rate and cardio-circulatory function in patients with septic shock. After informed consent, 60 patients with septic shock and persistent tachycardia (heart rate >95 /minute) were prospectively randomly assigned to receive either standard therapy for septic shock (group S) or standard therapy along with enteral ivabradine (group I) for the initial 96 hours after enrolment. Primary outcome was the difference in heart rate between the two groups during the first 96 hours. Secondary outcomes included the effect of ivabradine on haemodynamic, oxygenation, myocardial function and organ function parameters, incidence of adverse events and 30-day overall survival. Heart rate was lower in group I compared to group S (median difference in area under the curve -25.6 (95% confidence intervals -31.4 to -15.9) /minute; P <0.001). Vasopressor requirements, blood lactate levels, Sequential Organ Failure Assessment scores and E/e' ratio were lower in group I compared to group S. Stroke volume index and ejection fraction were higher in group I while cardiac index and oxygen delivery parameters were maintained similar to group S. There was no difference in 30-day mortality or in the incidence of serious adverse events. Enteral ivabradine is effective in reducing heart rate, and improving haemodynamic parameters and cardiac function in patients with septic shock and persistent tachycardia, without increasing the incidence of adverse events.

Background: Intravenous fluid optimization is an essential component of managing patients in a critical care setting. A cumulative positive fluid balance is consistent with poor outcomes in patients admitted to the intensive care unit (ICU). The overall utility of net cumulative fluid balance as a surrogate for assessing fluid overload has been interrogated., Materials and Methods: This study was a prospective single-center observational study, which was done to correlate body weight changes with fluid balance in ICU patients and evaluate its impact on clinical outcomes. Inclusion criteria consisted of adult patients who were admitted to the critical care unit on specialized beds with integrated weighing scales between September 2017 and December 2018. The evaluation of the effect of changes in body weight on ICU survival was the primary objective of the study., Results: We enrolled 105 patients in this study. The ICU mortality was 23.80% with non-survivors showing more weight gain than the survivors. Statistically significant weight gain was documented in the non-survivors on days 3 and 4 (1.9 vs 1.05; p = 0.0084 and 2.6 vs 1.6; p = 0.0030) of ICU admission. Non-survivors had greater cumulative positive fluid balance on fourth, fifth, and sixth days post-ICU admission when compared to survivors (3586 vs 1659 mL, p = 0.0322; 5418 vs 1255 mL, p = 0.0017; and 5430 vs 2305 mL p = 0.0264, respectively). In multivariate regression analysis, cumulative fluid balance did not correlate with days on mechanical ventilation or length of stay in ICU. Changes in body weight and cumulative fluid balance showed a good correlation., Conclusion: In patients admitted to the ICU, weight gain on third and fourth days of admission is concordant with increased ICU mortality. Body weight changes were seen to correlate well with the cumulative fluid balance., How to Cite This Article: Mishra RK, Pande A, Ramachandran R, Trikha A, Singh PM, Rewari V. Effect of Change in Body Weight on Clinical Outcomes in Critically Ill Patients. Indian J Crit Care Med 2021;25(9):1042-1048., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2021; Jaypee Brothers Medical Publishers (P) Ltd.)

Background: An effective analgesia strategy following caesarean delivery should be designed to improve fetomaternal outcomes. Much recent research has focused on the efficacy of ilioinguinal-iliohypogastric (II-IH) block for providing such analgesia., Design: A systematic review and meta-analysis of randomised controlled trials., Objectives: To investigate the effectiveness of II-IH block in patients undergoing caesarean delivery. The primary outcome was the cumulative parenteral morphine equivalents at 24 h. Pain scores at 4 to 6 and 24 h postsurgery, time to first rescue analgesia and adverse effects were the secondary outcomes analysed., Data Sources: Two reviewers searched independently PubMed, Embase, Google Scholar and the Cochrane central registers of a controlled trial from their inception until June 2020., Methodology: Prospective randomised control trials comparing II-IH block with either systemic analgesia alone or a placebo block (non-active controls) were eligible for inclusion. Only trials that reported their methods comprehensibly and transparently were included. Cochrane methodology was used to assess the risk of bias. Data are presented as mean difference with 95% confidence interval (CI)., Results: Thirteen trials comprising a total of 858 patients were included. Opioid (intravenous morphine equivalents) consumption was reduced by 15.57 mg (95% CI -19.87 to -11.28; P < 0.00001; I2 = 95%) during the first 24 h in patients receiving II-IH block when compared with placebo or no block. Patients receiving general anaesthesia showed a greater reduction in morphine requirement at 24 h than those receiving neuraxial anaesthesia. Adequate 'information size' for the above outcome was confirmed with trial sequential analysis to rule out the possibility of a false-positive result. II-IH also significantly reduced pain scores at rest more so at 4 to 6 h than at 24 h., Conclusions: Our study suggests that the use of II-IH blocks is associated with a lower 24 h requirement for intravenous morphine equivalents in patients undergoing caesarean delivery. However, given the methodological limitations, data should be interpreted with caution until more studies are available., (Copyright © 2020 European Society of Anaesthesiology and Intensive Care. Unauthorized reproduction of this article is prohibited.)

Background: We performed a systematic review using Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines to identify the best available patient-reported outcome measure (PROM) of postpartum pain., Methods: This review follows COSMIN guidelines. We searched four databases with no date limiters, for previously identified validated PROMs used to assess postpartum pain. PROMs evaluating more than one author-defined domain of postpartum pain were assessed. We sought studies evaluating psychometric properties. An overall rating was then assigned based upon COSMIN analysis, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the level of evidence for psychometric properties of included PROMs. These assessments were used to make recommendations and identify the best PROM to assess postpartum pain., Results: We identified 19 studies using seven PROMs (involving 3511 women), which evaluated postpartum pain. All included studies evaluated ≥1 psychometric property of the included PROMs. An adequate number of pain domains was assessed by the Brief Pain Inventory (BPI), Short Form-BPI (SF-BPI), and McGill Pain Questionnaire (MPQ). The SF-BPI was the only PROM to demonstrate adequate content validity and at least a low-level of evidence for sufficient internal consistency, resulting in a Class A recommendation (the best performing instrument, recommended for use)., Conclusion: SF-BPI is the best currently available PROM to assess postpartum pain. However, it fails to assess several important domains and only just met the criteria for a Class A recommendation. Future studies are warranted to develop, evaluate, and implement a new PROM designed to specifically assess postpartum pain., Competing Interests: Declarations of interest The authors declare that they have no conflicts of interest., (Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)